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National Healthcare Safety Network (NHSN) Report, Data Summary for 2011, Device-associated Module

Margaret A. Dudeck, MPH, CPH, Teresa C. Horan, MPH, Kelly D. Peterson, BBA, Katherine Allen-Bridson, RN, BSN, MScPH, CIC, Gloria Morrell, RN, MS, MSN, CIC, Angela Anttila, RN, MSN, NPC, CIC, Daniel A. Pollock, MD, and Jonathan R. Edwards, MStat

Posted online April 1, 2013This report is public domain and can be copied freely.

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National Center for Emerging and Zoonotic Infectious DiseasesDivision of Healthcare Quality Promotion

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Background This report is a summary of Device-associated (DA) Module data col-lected by hospitals participating in the National Healthcare Safety Network (NHSN) for events occurring from January through December 2011 and reported to the Centers for Disease Control and Prevention (CDC) by August 1, 2012. This report updates previously published DA Module data from NHSN and provides contempo-rary comparative rates.1 This report complements other NHSN reports, in-cluding national and state-specific re-ports of standardized infection ratios (SIRs) for select healthcare-associated infections (HAIs).2,3,4

NHSN data collection, reporting, and analysis are organized into three com-ponents: Patient Safety, Healthcare Personnel Safety, and Biovigilance, and use standardized methods and definitions in accordance with specific module protocols.5,6,7 Institutions may use modules singly or simultaneously, but once selected, they must be used for a minimum of one calendar month for the data to be included in CDC

analyses. All infections are catego-rized using standard CDC definitions that include laboratory and clinical criteria.7 The DA Module may be used by facilities other than hospitals, including outpatient dialysis centers. A report of data from this module for outpatient dialysis centers was published separately.8 NHSN facilities contributing HAI surveillance data to this report did so voluntarily, in re-sponse to state mandatory reporting requirements or in compliance with the Centers for Medicare and Medic-aid Services’ (CMS) Hospital Inpatient Quality Reporting (IQR) Program. CDC aggregated these data into a single national database for 2011, consistent with the stated purposes of NHSN, which were to:

• Collect data from a sample of healthcare facilities in the United States to permit valid estima-tion of the magnitude of adverse events among patients and healthcare personnel.

• Collect data from a sample of healthcare facilities in the United States to permit valid estimation of the adherence to practices known to be associated with pre-vention of these adverse events.

• Analyze and report collected data to permit recognition of trends.

• Provide facilities with risk-adjust-ed metrics that can be used for inter-facility comparisons and local quality improvement activi-ties.

• Assist facilities in developing sur-veillance and analysis methods that permit timely recognition of patient and healthcare worker safety problems and prompt intervention with appropriate measures.

• Conduct collaborative research studies with NHSN member fa-cilities (e.g., describe the epide-miology of emerging healthcare-associated infection [HAI] and pathogens, assess the impor-tance of potential risk factors, further characterize HAI patho-gens and their mechanisms of resistance, and evaluate alterna-tive surveillance and prevention strategies).

• Comply with legal requirements – including but not limited to state or federal laws, regulations, or other requirements – for man-datory reporting of healthcare facility-specific adverse event, prevention practice adherence, and other public health data.

• Enable healthcare facilities to re-port HAI and prevention practice adherence data via NHSN to the U.S. Centers for Medicare and Medicaid Services (CMS) in fulfill-ment of CMS’s quality measure-ment reporting requirements for those data.

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• Provide state departments of health with information that identifies the healthcare facilities in their state that participate in NHSN.

• Provide to state agencies, at their request, facility-specific, NHSN patient safety component and healthcare personnel safety component adverse event and prevention practice adherence data for surveillance, prevention, or mandatory public reporting.

Patient- and facility-specific data reported to CDC are kept confiden-tial in accordance with sections 304, 306, and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).

Methods

Data Collection MethodsFor reporting to the DA Module, healthcare facility personnel respon-sible for infection prevention and patient safety may choose, with con-sideration of state mandates, federal reporting programs, and prevention initiatives, to collect data on central line-associated primary bloodstream infections (CLABSI), ventilator-associated pneumonias (VAP), or urinary catheter-associated urinary tract infections (CAUTI) that occur in patients staying in a patient care location such as a critical or intensive care unit (ICU), specialty care area, or inpatient ward. In NHSN, locations are further stratified according to patient population: adults, children, or neonates (in tables, pediatric and neonatal locations are so noted). In neonatal intensive care unit (NICU) locations (level III or level II/III), infec-tion preventionists (IPs) collect data on central line-associated and um-bilical catheter-associated BSI or VAP that occur in patients in each of five birth-weight categories (≤750 g, 751-1000 g, 1001 - 1500 g, 1501 - 2500 g,

and >2500 g); data on CAUTI are not collected as part of the NHSN proto-cols in any NICU location. Correspond-ing location-specific denominator data consisting of patient-days and specific device-days are also collected by IPs or other trained personnel.

In non-NICU locations, the device-days consist of the total number of central line-days, urinary catheter-days, or ventilator-days. For specialty care areas, such as hematology/oncology and hematopoietic stem cell trans-plant locations, central line days are split into those with only a permanent central line vs. those with temporary central lines (with or without a perma-nent central line). In NICU locations, the device-days consist of the total number of central line-days and um-bilical catheter-days, or ventilator days for each birth-weight category.

Data Analysis MethodsCompared to the previous report, five new locations – pediatric surgical critical care, long term care rehabilita-tion unit, long term acute care critical care, long term acute care ward, and inpatient rehabilitation facility– had sufficient data to be included in this report.1

Locations were further stratified by unit bed size and/or major teaching status to determine if pooled mean rates, medians, and empirical distribu-tions significantly differed between two groups for all DA infections; if dif-ferences were present, the strata were retained for reporting. Comparisons of pooled mean rates were performed us-ing Poisson regression. These compari-sons could be influenced by potential outlier rates from locations with

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disproportionately large denominators. Therefore, greater weight was given to the results of nonparametric tests comparing the medians for location shift and empirical distributions for assessing differences across the range of reported rates. These nonparamet-ric comparisons by definition require no validity assumptions and provide test results that are not subject to the potential weighting influence of high or low rates with large denominators. Comparisons of the median and per-centile distribution were made if there were at least 50 locations contributing to one or more strata and at least 20 locations contributing to the percentile distribution in both strata.

Existing strata were retained for adult combined medical/surgical ICUs, med-ical ICUs, and surgical ICUs. The data for adult combined medical/surgical ICUs were split by hospital type and unit bedsize, resulting in three groups: “major teaching,” “all others” with unit bedsize ≤15 beds, and “all others” with unit bedsize >15. The data for adult medical ICUs and adult surgical ICUs were split into two groups by teaching status. Facilities self-identi-fied teaching status through an annual facility survey. Major teaching status was defined as a hospital that is an important part of the medical school teaching program in which the major-ity of medical students rotate through multiple clinical services. Adult bone marrow transplant and adult hema-tology/oncology locations were also evaluated to assess importance of status as an oncology hospital, but dif-ferences were not significant and no new strata were retained.

Device utilization (DU) was calculated as a ratio of device days to patient days for each location type. As such, the DU of a location is one measure of the use of invasive devices and constitutes an extrinsic risk factor for healthcare-associated infection.9 DU may also serve as a marker for sever-ity of illness of patients (i.e. more

severely ill patients are more likely to require an invasive device) which is another reflection of the intrinsic susceptibility to infection.

Data from at least 5 different report-ing units of a given location type were used to determine pooled mean DA infection rates and DU ratios. Percen-tile distributions were determined if there were data from at least 20 dif-ferent locations, excluding rates or DU ratios for locations that did not report at least 50 device-days or patient-days. Because of these requirements, the number of locations contributing data may vary among the tables.

Results In 2011, 3,854 hospitals reported at least one month of DA denominator data for some patient cohorts under surveillance. These 3,854 hospitals were located in 53 states, territories, and the District of Columbia and were predominantly general acute care hos-pitals (Table 1); approximately two-thirds were smaller hospitals of 200

beds or less (65%), and only 10.9% were categorized as major teaching facilities (Table 2). Additionally, 60% of the hospitals included in this report are located in states with a mandate for reporting at least one type of DA infection to NHSN. Where data vol-ume was sufficient for this report, we tabulated DA infection rates and DU ratios for January through December 2011 (Tables 3-10). Data on the spe-cific criteria used to report DA infec-tions are provided in Tables 11-18.

Tables 3-6 update and augment previously published DA rates and DU ratios by type of non-NICU locations.1 Beginning in 2012, long term acute care (LTAC) units were re-categorized by acuity level into critical care or ward designations; therefore, in order to align with current data reporting methods in this location type, LTAC data in this report have been catego-rized in the same manner. Addition-ally, data from inpatient rehabilitation facilities (IRFs), as defined by the Centers for Medicare and Medicaid Services (CMS), have been reported separately from non-IRF rehabilitation wards within acute care hospitals.

Tables 7-10 update and augment the previously published, DA rates and DU ratios by birth-weight category for NICU locations.1 Beginning in January 2012, CLABSI data in NICU locations are no longer collected according to central line type (i.e., central line and umbili-cal catheter); in order to align with the current reporting of these data, CLABSI rates and DU ratios for NICUs are not stratified by line type in this report.

Tables 11-18 provide data on select attributes of the DA infections for each location. For example, Tables 11, 12, 15 and 16 show the frequency and percent distribution of the specific sites of CLABSI and the criteria used for identifying these infections. Note that for these tables, criteria 2 and 3 have been combined.

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DiscussionThis report summarizes the HAI data reported to the DA module of NHSN during 2011. The data in this report continue to be restricted to a single year for several reasons. First, NHSN saw continued growth in participation due to state mandates and federal re-porting programs and because of this, there were sufficient data reported in 2011 to support the analysis of a single year of data (e.g., consider-able data contributing to the pooled means, most location types with >20 locations reporting), thus obviating the need to combine data with previ-ous years. Second, analyzing one year of data removes the need to assess the influence of any large increase of new reporters in a single year of a multiyear summary measure. Finally, by restricting data to a single year, changes in HAI rates are more ap-parent and can highlight continued prevention efforts in different patient care areas. This strategy also fulfills the need for more timely publication of comparative rates.

The characteristics of hospitals report-ing to NHSN are similar to those seen in the last published report, although this report demonstrates a slight increase in contribution from smaller hospitals.1 Based on the number of facilities reporting, overall contribu-tion to the device-associated mod-ule increased by 56% from the last report.1 This increase in reporting is largely attributed to hospitals’ partici-pation in the CMS Hospital Inpatient Quality Reporting Program which requires participants to use NHSN as the tool to report CLABSI data from all adult, pediatric, and neonatal ICUs be-ginning in January 2011. While much of this growth impacted the volume of CLABSI reporting in ICUs, there is an indication of increased participation in non-ICU locations for CLABSI report-ing, as well as reporting for other HAIs in this module.

Extensive analyses of the impact of hospital type on all DA infection rates were performed for select ICU loca-tions. Hospital type continues to be a significant factor for all three DA infec-tion rates and percentile distributions in medical ICUs and surgical ICUs. Ad-ditionally, hospital type and bed size both continue to be significant factors in DA infection rates for medical/surgi-cal ICUs. Note that while the CLABSI rates between unit bedsize strata in medical/surgical “all other” ICUs are equal (Table 3), the percentile distri-butions were shown to be significantly different as a result of nonparametric statistical tests. Therefore, this strati-fication by unit bedsize in “all other” medical/surgical ICUs was retained. Adult bone marrow transplant and adult hematology/oncology locations were not further stratified by hospital type (i.e., oncology hospital vs. all oth-er acute care hospitals) as the results of the statistical tests indicated that the differences in the strata were not statistically significant. Beginning in 2013, oncology hospitals will be pro-vided with fourteen oncology-specific CDC locations with which to identify

for device-associated infection surveil-lance. As the volume of these data become sufficient, future analyses will continue to assess any potential differ-ences in this specialized population.

Tables 11-18 were included to aid the reader in interpreting the DA infec-tion rates data. One important use of these data is to better understand the distribution of DA infections by type of reporting criterion nationally. For example, approximately 82% of the CLABSIs from adult and pediatric ICU and inpatient wards were identi-fied using the least subjective crite-rion (1) which attributes the CLABSI to a recognized pathogen; however, for NICUs, approximately two-thirds used this criterion, resulting in a greater percentage of CLABSIs in this population that were identified with common commensals. Similarly, the specific type of ventilator-associated pneumonia (VAP) most frequently re-ported, regardless of location, was the clinical criterion (PNU1) which relies on the somewhat subjective interpre-tations of clinical findings.

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As more and diverse types of facilities participate in NHSN either voluntarily or by mandate, the need for careful scrutiny of the data increases. We will continue to assess how the chang-ing composition of facilities and the changing proportion of data contribut-ed by various types of facilities impact the rates and their distributions so that the best possible risk-adjusted comparative data may be provided in future reports.

To improve the reliability of data reported to NHSN, several protocol changes are set to occur in January 2013. The majority of these changes are with respect to timing and imple-mentation of two-day rules to clarify infections that are healthcare-associ-ated, association of device use to HAI, and attribution of HAI to an inpatient location after transfer or to a hospital after discharge. In addition, NHSN will add criteria for mucosal barrier injury laboratory-confirmed bloodstream infections. Finally, the VAP definition

will no longer apply to adult patients (i.e., ≥ 18 years of age) and this defini-tion will be replaced by ventilator-associated events (VAEs).10 We will carefully assess the potential impact of these changes on HAI incidence as these data are reported.

For those who do not report to NHSN but would like to use these data for comparison, the information must first be collected from your hospital in accordance with the methods de-scribed for NHSN.5,6,7 Refer to Appen-dices A and B for further instructions. Appendix A discusses the calculation of infection rates and DU ratios for the DA Module. Appendix B gives a step-by-step method for interpretation of percentiles of infection rates or DU ratios. Although a high rate or ratio (>90th percentile) does not necessar-ily define a problem, it does suggest an area for further investigation. Simi-larly, a low rate or ratio (<10th percen-tile) may be the result of inadequate infection detection.

Facilities should use the data in this report and their own data to guide local prevention strategies and other quality improvement efforts to reduce the occurrence of infections as much as possible. The data presented in this report can be used to prioritize pre-vention efforts in those patient care areas that are shown to have the high-est incidence of DA infections and/or high device utilization. Facilities may also wish to set targets based on the percentile distributions provided in this report in an effort to strive for lower rates and greater prevention success.

The authors are indebted to the NHSN participants for their ongoing efforts to monitor infections and improve patient safety. We also gratefully acknowl-edge our colleagues in the Division of Healthcare Quality Promotion who tirelessly support this unique public health network.

The findings and conclusions of the report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

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Table 1. NHSN hospitals contributing data used in this report

Hospital type N (%)Children’s 62 (1.6)General, including acute, trauma, and teaching 3,426 (88.9)Long Term Acute Care 192 (5.0)Military 25 (0.6)Oncology 10 (0.3)Orthopedic 13 (0.3)Psychiatric 10 (0.3)Rehabilitation 44 (1.1)Surgical 41 (1.1)Veterans Affairs 16 (0.4)Women’s 5 (0.1)Women’s and Children’s 10 (0.3)Total 3,854 (10 0.0)

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Table 2. NHSN hospitals contributing data used in this report by hospital type and bedsize

Hospital type

Bed size category

Total <= 200 201-500 501-1000 > 1000N (%) N (%) N (%) N (%)

Major teaching 104 (2.7) 185 (4.8) 123 (3.2) 9 (0.2) 421 (10.9)Graduate teaching 125 (3.2) 153 (4.0) 35 (0.9) 3 (0.1) 316 (8.2)Limited teaching 193 (5.0) 157 (4.1) 30 (0.8) 1 (0.0) 381 (9.9)Nonteaching 2,085 (54.1) 594 (15.4) 55 (1.4) 2 (0.0) 2736 (71.0)Total 2,807 (65.0) 1,089 (28.3) 243 (6.3) 15 (0.4) 3,854 (100)

Major: Hospital is an important part of the teaching program of a medical school and the majority of medical students rotate through multiple clinical services.

Graduate: Hospital is used by the medical school for graduate training programs only; i.e., residency and/or fellowships.Limited: Hospital is used in the medical school’s teaching program only to a limited extent.

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Table 3. Pooled means and key percentiles of the distribution of laboratory-confirmed central line-associated BSI rates and central line utilization ratios, by type of location, DA module, 2011

Central line-associated BSI rate* Percentile

Type of Location No.

of

loca

tions

+

No.

of

CLAB

SIs

Cent

ral

line-

days

Pool

ed

mea

n

10%

25%

50%

(m

edia

n)

75%

90%

Acute Care Hospitals

Critical CareBurn 71 (70) 301 80,426 3.7 0.0 1.2 2.8 5.8 8.4Medical -Major teaching 198 (197) 703 563,577 1.2 0.0 0.4 1.1 1.8 2.9Medical -All other 476 (451) 769 675,620 1.1 0.0 0.0 0.5 1.6 2.9Medical cardiac 423 (415) 673 605,187 1.1 0.0 0.0 0.8 1.7 2.8Medical/surgical -Major teaching 304 (300) 937 693,570 1.4 0.0 0.0 1.1 1.9 3.1Medical/surgical -All other ≤15 beds 1,860 (1669) 1,246 1,416,501 0.9 0.0 0.0 0.0 1.1 2.5Medical/surgical -All other > 15 beds 800 (795) 1,959 2,174,055 0.9 0.0 0.2 0.7 1.4 2.2Neurologic 50 76 76,580 1.0 0.0 0.0 0.7 1.6 2.2Neurosurgical 166 309 300,009 1.0 0.0 0.0 0.8 1.6 2.3Pediatric cardiothoracic 38 180 110,127 1.6 0.0 1.1 1.6 2.1 2.7Pediatric medical 36 (29) 34 24,777 1.4 0.0 0.0 0.0 1.6 2.7Pediatric medical/surgical 300 (281) 717 403,728 1.8 0.0 0.0 1.3 2.6 4.1Pediatric surgical 6 (5) 3 3,473 0.9Prenatal 8 (3) 0 330 0.0Respiratory 10 8 14,524 0.6Surgical -Major teaching 161 514 435,010 1.2 0.0 0.2 1.0 1.9 3.1Surgical -All other 218 (214) 429 419,669 1.0 0.0 0.0 0.8 1.6 2.8Surgical cardiothoracic 457 (456) 762 934,275 0.8 0.0 0.0 0.5 1.1 1.9Trauma 140 511 328,713 1.6 0.0 0.5 1.3 2.4 3.3Step-Down UnitsAdult step-down (post-critical care) 502 (493) 588 607,681 1.0 0.0 0.0 0.0 1.2 2.5Step-down NICU (level II) 42 (20) 8 5,366 1.5 0.0 0.0 0.0 0.0 1.0Pediatric step-down (post-critical care) 11 19 9,430 2.0Inpatient WardsAcute stroke 17 10 12,742 0.8Antenatal 11 (4) 1 1,988 0.5Behavioral health/psychiatry 94 (29) 4 7,253 0.6 0.0 0.0 0.0 0.0 0.2Burn 15 5 6,451 0.8Genitourinary 13 19 20,684 0.9Geronotology 9 (8) 7 7,050 1.0Gynecology 47 (26) 7 13,137 0.5 0.0 0.0 0.0 0.0 0.7Jail 17 (16) 11 9,875 1.1Labor and delivery 48 (7) 0 950 0.0Labor, delivery, recovery, postpartum suite 89 (14) 1 3,223 0.3Medical 770 (735) 908 963,923 0.9 0.0 0.0 0.3 1.5 2.9Medical/surgical 1,892 (1,756) 1,606 1,844,384 0.9 0.0 0.0 0.0 1.2 2.4Neurologic 49 (48) 44 56,575 0.8 0.0 0.0 0.0 1.1 2.5Neurosurgical 57 (56) 47 59,918 0.8 0.0 0.0 0.0 0.8 2.0Orthopedic 242 (213) 98 158,131 0.6 0.0 0.0 0.0 0.8 1.6Orthopedic trauma 15 32 18,907 1.7Pediatric medical 47 (42) 62 50,476 1.2 0.0 0.0 0.0 1.6 2.9Pediatric medical/surgical 241 (185) 197 170,549 1.2 0.0 0.0 0.0 1.6 3.5Pediatric rehabilitation|| 8 7 6,737 1.0Pediatric surgical 11 21 16,215 1.3Postpartum 128 (11) 1 2,648 0.4

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Pulmonary 31 52 55,230 0.9 0.0 0.0 0.7 1.4 2.3Rehabilitation - non-IRF|| 71 (65) 10 32,617 0.3 0.0 0.0 0.0 0.0 1.4Surgical 444 (421) 410 506,033 0.8 0.0 0.0 0.0 1.1 2.3Telemetry 225 (219) 188 219,853 0.9 0.0 0.0 0.0 1.4 3.0Vascular Surgery 23 14 35,321 0.4 0.0 0.0 0.0 0.7 1.2Well-Baby Nursery 16 (5) 2 640 3.1Inpatient Long Term Care§

Chronic care 15 (13) 5 11,338 0.4Ventilator dependent unit 6 19 10,806 1.8Long-Term Acute Care Hospitals‡Adult critical care 18 76 38,805 2.0Adult Ward 229 (227) 1,431 1,205,212 1.2 0.0 0.3 1.0 1.8 2.9Inpatient Rehabilitation Facilities¶

Adult rehabilitation units - Freestanding 77 (73) 23 51,943 0.4 0.0 0.0 0.0 0.4 1.7Adult rehabilitation units - Within hospital 167 (162) 43 77,585 0.6 0.0 0.0 0.0 0.0 2.5

Central line utilization ratio** Percentile


of

loca

tions

+

Cent

ral

line-

days

Patie

nt-

days

Pool

ed

mea

n

10%

25%

50%

(m

edia

n)

75%

90%


Critical CareBurn 71 (70) 80,426 172,984 0.46 0.22 0.35 0.45 0.57 0.78Medical -Major teaching 198 563,577 913,585 0.62 0.42 0.54 0.62 0.70 0.78Medical -All other 476 (471) 675,620 1,487,717 0.45 0.13 0.25 0.43 0.58 0.71Medical cardiac 423 (422) 605,187 1,427,575 0.42 0.19 0.29 0.42 0.56 0.68Medical/surgical -Major teaching 304 (303) 693,570 1,291,401 0.54 0.26 0.42 0.55 0.66 0.74Medical/surgical -All other ≤15 beds 1,860 (1,822) 1,416,501 4,069,614 0.35 0.10 0.18 0.33 0.50 0.63Medical/surgical -All other > 15 beds 800 2,174,055 4,420,558 0.49 0.30 0.40 0.51 0.61 0.71Neurologic 50 76,580 152,036 0.50 0.23 0.37 0.48 0.59 0.70Neurosurgical 166 300,009 683,553 0.44 0.28 0.36 0.45 0.54 0.62Pediatric cardiothoracic 38 110,127 156,466 0.70 0.48 0.61 0.73 0.86 0.91Pediatric medical 36 (34) 24,777 65,428 0.38 0.07 0.15 0.25 0.44 0.53Pediatric medical/surgical 300 (295) 403,728 866,685 0.47 0.14 0.25 0.39 0.53 0.61Pediatric surgical 6 3,473 8,516 0.41Prenatal 8 330 7,408 0.04Respiratory 10 14,524 30,748 0.47Surgical -Major teaching 161 435,010 699,783 0.62 0.41 0.52 0.60 0.72 0.80Surgical -All other 218 (215) 419,669 746,500 0.56 0.37 0.46 0.56 0.68 0.77Surgical cardiothoracic 457 934,275 1,425,711 0.66 0.40 0.50 0.67 0.81 0.91Trauma 140 328,713 601,489 0.55 0.36 0.45 0.57 0.65 0.72Step-Down UnitsAdult step-down (post-critical care) 502 (499) 607,681 2,949,613 0.21 0.08 0.12 0.18 0.29 0.41Step-down NICU (level II) 42 (41) 5,366 52,925 0.10 0.02 0.04 0.07 0.13 0.17Pediatric step-down (post-critical care) 11 9,430 37,574 0.25Inpatient WardsAcute stroke 17 12,742 93,295 0.14Antenatal 11 1,988 42,651 0.05Behavioral health/psychiatry 94 7,253 228,529 0.03 0.01 0.01 0.02 0.03 0.05Burn 15 6,451 35,906 0.18Genitourinary 13 20,684 85,847 0.24Geronotology 9 7,050 57,819 0.12

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Gynecology 47 13,137 123,917 0.11 0.01 0.01 0.04 0.13 0.29Jail 17 9,875 55,242 0.18Labor and delivery 48 (45) 950 44,530 0.02 0.00 0.01 0.01 0.03 0.11Labor, delivery, recovery, postpartum suite 89 (88) 3,223 121,634 0.03 0.00 0.01 0.02 0.03 0.04Medical 770 (766) 963,923 5,421,265 0.18 0.06 0.10 0.15 0.22 0.32Medical/surgical 1,892 (1,888) 1,844,384 12,356,081 0.15 0.04 0.07 0.12 0.18 0.25Neurologic 49 56,575 366,417 0.15 0.07 0.11 0.13 0.19 0.25Neurosurgical 57 59,918 401,591 0.15 0.07 0.09 0.15 0.20 0.25Orthopedic 242 (241) 158,131 1,478,952 0.11 0.02 0.05 0.09 0.13 0.18Orthopedic trauma 15 18,907 114,147 0.17Pediatric medical 47 (46) 50,476 212,541 0.24 0.03 0.09 0.18 0.31 0.37Pediatric medical/surgical 241 (239) 170,549 923,148 0.18 0.03 0.04 0.11 0.23 0.32Pediatric rehabilitation|| 8 6,737 32,984 0.20Pediatric surgical 11 16,215 64,153 0.25Postpartum 128 2,648 258,807 0.01 0.00 0.00 0.01 0.01 0.03Pulmonary 31 55,230 233,443 0.24 0.10 0.15 0.21 0.31 0.45Rehabilitation - non-IRF|| 71 32,617 302,440 0.11 0.04 0.06 0.08 0.14 0.25Surgical 444 (440) 506,033 2,955,338 0.17 0.05 0.09 0.15 0.21 0.27Telemetry 225 (223) 219,853 1,646,413 0.13 0.06 0.09 0.13 0.17 0.22Vascular Surgery 23 35,321 158,729 0.22 0.09 0.14 0.19 0.31 0.45Well-Baby Nursery 16 640 15,265 0.04Inpatient Long Term Care§

Chronic care 15 (13) 11,338 67,078 0.17Ventilator dependent unit 6 10,806 33,390 0.32Long-Term Acute Care Hospitals‡Adult critical care 18 38,805 69,278 0.56Adult Ward 229 1,205,212 1,901,569 0.63 0.43 0.54 0.69 0.79 0.87Inpatient Rehabilitation Facilities¶

Adult rehabilitation units - Freestanding 77 51,943 694,684 0.07 0.03 0.04 0.06 0.09 0.13Adult rehabilitation units - Within hospital 167 77,585 761,155 0.10 0.04 0.06 0.08 0.13 0.18

CLABSI, central line-associated bloodstream infection; NICU, neonatal intensive care unit.

* Number of CLABSI x 1000 Number of central line-days

** Number of central line-days Number of patient-days

BSI, bloodstream infection; CLABSI, central line-associated BSI.

† The number in parentheses is the number of locations meeting minimum requirements for percentile distributions (i.e., ≥ 50 device days for rate distributions, ≥ 50 patient days for device utilization ratios) if less than total number of locations. If this number < 20, percentile distribu-tions are not calculated.

‡ Includes free-standing long-term acute care hospitals and long-term acute care locations within the general acute care hospital setting.

§ Includes inpatient long term care locations within the general acute care hospital setting. || Includes only in-hospital rehabilitation wards that are not defined as inpatient rehabilitation facilities (IRF) per the CMS Inpatient Rehabilita-

tion Facility Quality Reporting Program.

¶ Includes free-standing inpatient rehabilitation facilities and inpatient rehabilitation facilities within the acute care hospital setting, as defined by the CMS Inpatient Rehabilitation Facility Quality Reporting Program.

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Table 4. Pooled means and key percentiles of the distribution of laboratory-confirmed permanent and temporary central line-associated BSI rates and central line utilization ratios, by type of speciality care area/oncology location, DA module, 2011

Permanent Central line-associated BSI rate* Percentile


of

loca

tions

+

No.

of

PCLA

BSIs

Perm

anen

t Ce

ntra

l lin

e-

days

Pool

ed

mea

n

10%

25%

50%

(m

edia

n)

75%

90%

Specialty Care Area/OncologyHematopoietic stem cell transplant 49 (48) 285 117,264 2.4 0.0 0.9 1.9 3.8 5.3General hematology/oncology 163 (162) 400 295,200 1.4 0.0 0.0 1.0 1.9 3.1Pediatric hematopoietic stem cell transplant 13 67 30,530 2.2Pediatric general hematology/oncology 40 212 127,444 1.7 0.0 0.6 1.6 2.2 3.3Solid organ transplant 19 (15) 27 16,448 1.6

Temporary Central line-associated BSI rate** Percentile


of

loca

tions

+

No.

of

TCLA

BSI

Tem

pora

ryCe

ntra

l lin

e-da

ys

Pool

ed

mea

n

10%

25%

50%

(m

edia

n)

75%

90%

Specialty Care Area/OncologyHematopoietic stem cell transplant 48 (47) 204 87,507 2.3 0.0 0.9 1.8 3.2 4.7General hematology/oncology 170 (169) 475 243,144 2.0 0.0 0.0 1.4 2.8 4.7Pediatric hematopoietic stem cell transplant 11 (8) 11 5,193 2.1Pediatric general hematology/oncology 41 (39) 84 37,815 2.2 0.0 0.0 1.0 3.3 4.8Solid organ transplant 19 58 34,735 1.7

Permanent Central line utilization ratio# Percentile


of

loca

tions

+

Perm

anen

tCe

ntra

l lin

e-da

ys

Patie

nt-d

ays

Pool

ed

mea

n

10%

25%

50%

(m

edia

n)

75%

90%

Specialty Care Area/OncologyHematopoietic stem cell transplant 49 117,264 227,282 0.52 0.16 0.28 0.50 0.67 0.81General hematology/oncology 163 295,200 984,067 0.30 0.12 0.18 0.28 0.40 0.53Pediatric hematopoietic stem cell transplant 13 30,530 39,571 0.77Pediatric general hematology/oncology 40 127,444 206,284 0.62 0.34 0.44 0.59 0.79 0.84Solid organ transplant 19 (18) 16,448 101,176 0.16

13

Temporary Central line utilization ratio## Percentile


of

loca

tions

+

Tem

pora

ryCe

ntra

l lin

e-da

ys

Patie

nt-d

ays

Pool

ed m

ean

10%

25%

50%

(m

edia

n)

75%

90%

Specialty Care Area/OncologyHematopoietic stem cell transplant 48 87,507 210,124 0.42 0.10 0.28 0.40 0.62 0.74General hematology/oncology 170 243,144 1,045,450 0.23 0.08 0.14 0.21 0.32 0.44Pediatric hematopoietic stem cell transplant 11 5,193 29,099 0.18Pediatric general hematology/oncology 41 37,815 198,657 0.19 0.05 0.07 0.13 0.31 0.41Solid organ transplant 19 34,735 111,538 0.31

BSI, bloodstream infection; PCLABSI, permanent central line-associated BSI; TCLABSI, temporary central line-associated BSI

* Number of PCLABSI x 1000 Number of permanent central line-days

** Number of TCLABSI x 1000 Number of temporary central line-days

# Number of permanent central line-days Number of patient-days

## Number of temporary central line-days Number of patient-days

† The number in parentheses is the number of locations meeting minimum requirements for percentile distributions (i.e., ≥ 50 device days for rate distributions, ≥ 50 patient days for device utilization ratios) if less than total number of locations. If this number is < 20, percentile distribu-tions are not calculated.

14

Table 5. Pooled means and key percentiles of the distribution of urinary catheter-associated UTI rates and urinary catheter utilization ratios, by type of location, DA module, 2011

Urinary catheter-associated UTI rate* Percentile


of

loca

tions

+

No.

of

CAU

TI

Urin

ary

cath

eter

-da

ys

Pool

ed

mea

n

10%

25%

50%

(m

edia

n)

75%

90%


Critical Care UnitsBurn 38 148 36,222 4.1 0.0 0.0 2.8 5.2 8.6Medical -Major teaching 99 739 287,880 2.6 0.0 0.7 2.0 3.4 5.0Medical -All other 212 (202) 552 350,509 1.6 0.0 0.0 0.7 2.1 3.5Medical cardiac 211 (207) 596 301,884 2.0 0.0 0.0 1.3 2.9 5.0Medical/surgical -Major teaching 146 (145) 827 381,416 2.2 0.0 0.1 1.6 2.8 4.5Medical/surgical -All other ≤15 beds 793 (748) 921 750,795 1.2 0.0 0.0 0.0 1.6 3.5Medical/surgical -All other > 15 beds 405 1,685 1,181,301 1.4 0.0 0.4 1.1 2.1 3.1Neurologic 21 116 34,422 3.4 0.0 1.5 2.5 4.9 6.6Neurosurgical 74 812 181,986 4.5 0.0 1.8 3.8 5.5 8.1Pediatric cardiothoracic 10 (9) 12 8,764 1.4Pediatric medical 11 (10) 5 1,736 2.9Pediatric medical/surgical 129 (110) 217 70,607 3.1 0.0 0.0 0.8 3.5 8.0Prenatal 6 (2) 1 781 1.3Respiratory 6 11 7,869 1.4Surgical -Major teaching 75 552 213,845 2.6 0.4 1.2 2.1 3.5 5.1Surgical -All other 103 (102) 366 185,967 2.0 0.0 0.1 1.3 2.5 4.4Surgical cardiothoracic 216 (213) 560 356,842 1.6 0.0 0.0 1.0 2.2 3.4Trauma 75 776 230,687 3.4 0.2 1.3 2.5 4.1 6.0Specialty Care Areas/OncologyHematopoietic stem cell transplant 31 (29) 28 15,218 1.8 0.0 0.0 0.0 2.8 4.6General hematology/oncology 93 (91) 162 76,670 2.1 0.0 0.5 1.9 3.1 4.7Pediatric general hematology/oncology 10 (7) 4 1,213 3.3Solid organ transplant 10 21 12,370 1.7Step-Down UnitsAdult step-down (post-critical care) 318 (313) 764 439,142 1.7 0.0 0.0 1.3 2.7 4.5Pediatric step-down (post-critical care) 7 (5) 3 709 4.2Inpatient WardsAcute stroke 11 23 13,825 1.7Antenatal 7 0 971 0.0Behavioral health/psychiatry 91 (31) 19 7,517 2.5 0.0 0.0 0.0 0.2 8.1Burn 10 (9) 11 2,278 4.8Genitourinary 7 16 8,166 2.0Gerontology 9 (8) 11 6,052 1.8Gynecology 41 (36) 17 25,605 0.7 0.0 0.0 0.0 0.0 2.2Jail 7 (4) 4 2,344 1.7Labor and delivery 53 (39) 5 22,350 0.2 0.0 0.0 0.0 0.0 0.1Labor, delivery, recovery, postpartum suite 118 (100) 16 37,717 0.4 0.0 0.0 0.0 0.0 0.0Medical 577 (566) 979 646,918 1.5 0.0 0.0 1.0 2.4 3.9Medical/Surgical 1,345 (1,292) 1,979 1,484,664 1.3 0.0 0.0 0.8 2.0 3.5Neurologic 34 95 44,538 2.1 0.0 0.5 1.5 3.8 5.2Neurosurgical 35 126 51,830 2.4 0.0 0.5 1.5 3.8 6.1Orthopedic 169 (166) 308 233,542 1.3 0.0 0.0 0.8 2.0 3.8Orthopedic trauma 10 32 17,818 1.8Pediatric medical/surgical 141 (73) 38 27,035 1.4 0.0 0.0 0.0 2.0 5.1

15

Pediatric medical 27 (11) 6 3,703 1.6Pediatric surgical 7 (6) 9 6,293 1.4Postpartum 140 (133) 32 68,027 0.5 0.0 0.0 0.0 0.0 1.7Pulmonary 22 67 34,677 1.9 0.0 0.3 1.1 3.0 3.8Rehabilitation - non-IRF|| 43 (40) 45 14,210 3.2 0.0 0.0 0.0 4.3 10.1Surgical 313 (308) 660 437,413 1.5 0.0 0.0 1.0 2.2 4.3Telemetry 90 (88) 132 114,507 1.2 0.0 0.0 0.8 1.9 3.8Vascular surgery 10 15 10,396 1.4Well-baby nursery 8 (1) 0 126 0.0Inpatient Long Term Care§

Chronic care 16 (5) 12 7,945 1.5Long-term care rehabilitation unit 8 18 2,550 7.1Long-Term Acute Care Hospitals‡Adult critical care 6 17 4,777 3.6Adult Ward 166 (165) 1,407 652,175 2.2 0.0 0.9 1.8 3.1 4.8Inpatient Rehabilitation Facilities¶

Adult rehabilitation units - Freestanding 82 (81) 164 54,732 3.0 0.0 0.0 1.4 3.9 6.5Adult rehabilitation units - Within hospital 138 (126) 147 47,869 3.1 0.0 0.0 1.1 5.2 9.0

Urinary catheter utilization ratio** Percentile


of

loca

tions

+

Urin

ary

cath

eter

-da

ys

Patie

ntda

ys

Pool

ed

mea

n

10%

25%

50%

(m

edia

n)

75%

90%


Critical Care UnitsBurn 38 36,222 72,139 0.50 0.34 0.38 0.45 0.64 0.76Medical -Major teaching 99 287,880 410,123 0.70 0.56 0.65 0.74 0.80 0.85Medical -All other 212 (210) 350,509 570,682 0.61 0.33 0.53 0.68 0.78 0.85Medical cardiac 211 (210) 301,884 597,741 0.51 0.25 0.38 0.53 0.66 0.74Medical/surgical -Major teaching 146 (145) 381,416 551,855 0.69 0.49 0.62 0.74 0.80 0.83Medical/surgical -All other ≤15 beds 793 (766) 750,795 1,399,138 0.54 0.31 0.46 0.61 0.73 0.81Medical/surgical -All other > 15 beds 405 1,181,301 1,776,793 0.66 0.49 0.60 0.71 0.78 0.84Neurologic 21 34,422 48,549 0.71 0.32 0.56 0.73 0.82 0.84Neurosurgical 74 181,986 261,682 0.70 0.54 0.61 0.71 0.79 0.85Pediatric cardiothoracic 10 8,764 45,281 0.19Pediatric medical 11 1,736 14,045 0.12Pediatric medical/surgical 129 (126) 70,607 311,974 0.23 0.07 0.12 0.20 0.26 0.32Prenatal 6 781 7,926 0.10Respiratory 6 7,869 17,388 0.45Surgical -Major teaching 75 213,845 282,221 0.76 0.58 0.70 0.77 0.83 0.88Surgical -All other 103 (102) 185,967 261,357 0.71 0.45 0.64 0.75 0.81 0.89Surgical cardiothoracic 216 (215) 356,842 530,154 0.67 0.41 0.55 0.69 0.82 0.88Trauma 75 230,687 292,809 0.79 0.62 0.74 0.80 0.87 0.94Specialty Care Areas/OncologyHematopoietic stem cell transplant 31 15,218 135,776 0.11 0.04 0.05 0.07 0.15 0.24General hematology/oncology 93 (92) 76,670 492,732 0.16 0.07 0.09 0.15 0.21 0.30Pediatric general hematology/oncology 10 1,213 49,541 0.02Solid organ transplant 10 12,370 61,782 0.20Step-Down UnitsAdult step-down (post-critical care) 318 439,142 1,708,256 0.26 0.12 0.17 0.25 0.37 0.52Pediatric step-down (post-critical care) 7 709 21,427 0.03

16

Inpatient WardsAcute stroke 11 13,825 40,059 0.35Antenatal 7 971 9,257 0.10Behavioral health/psychiatry 91 7,517 216,343 0.03 0.00 0.01 0.02 0.04 0.07Burn 10 2,278 15,692 0.15Genitourinary 7 8,166 48,061 0.17Gerontology 9 6,052 48,732 0.12Gynecology 41 25,605 124,166 0.21 0.07 0.12 0.20 0.29 0.47Jail 7 2,344 24,249 0.10Labor and delivery 53 22,350 101,221 0.22 0.02 0.06 0.13 0.20 0.44Labor, delivery, recovery, postpartum suite 118 (116) 37,717 243,461 0.15 0.06 0.10 0.13 0.19 0.28Medical 577 (574) 646,918 3,758,665 0.17 0.08 0.12 0.17 0.22 0.30Medical/Surgical 1,345 (1,335) 1,484,664 7,712,951 0.19 0.10 0.13 0.18 0.24 0.31Neurologic 34 44,538 213,695 0.21 0.09 0.15 0.20 0.24 0.36Neurosurgical 35 51,830 229,333 0.23 0.10 0.17 0.21 0.32 0.50Orthopedic 169 233,542 869,225 0.27 0.13 0.20 0.27 0.34 0.44Orthopedic trauma 10 17,818 76,451 0.23Pediatric medical/surgical 141 (138) 27,035 382,338 0.07 0.01 0.01 0.04 0.08 0.15Pediatric medical 27 (26) 3,703 81,712 0.05 0.01 0.01 0.01 0.03 0.16Pediatric surgical 7 6,293 39,998 0.16Postpartum 140 68,027 519,219 0.13 0.03 0.08 0.13 0.19 0.29Pulmonary 22 34,677 154,604 0.22 0.09 0.16 0.19 0.23 0.50Rehabilitation - non-IRF|| 43 14,210 166,012 0.09 0.03 0.05 0.07 0.13 0.16Surgical 313 (311) 437,413 1,875,890 0.23 0.12 0.17 0.23 0.30 0.40Telemetry 90 (89) 114,507 548,651 0.21 0.10 0.15 0.21 0.25 0.31Vascular surgery 10 10,396 65,192 0.16Well-baby nursery 8 (7) 126 2,149 0.06Inpatient Long Term Care§

Chronic care 16 (13) 7,945 41,541 0.19Long-term care rehabilitation unit 8 2,550 38,741 0.07Long-Term Acute Care Hospitals‡

Adult critical care 6 4,777 11,806 0.40Adult Ward 166 652,175 1,258,801 0.52 0.31 0.43 0.51 0.62 0.71Inpatient Rehabilitation Facilities¶

Adult rehabilitation units - Freestanding 82 54,732 700,414 0.08 0.03 0.05 0.07 0.09 0.13Adult rehabilitation units - Within hospital 138 47,869 521,238 0.09 0.03 0.05 0.08 0.12 0.16




BSI, bloodstream infection; CLABSI, central line-associated BSI.



§ Includes inpatient long term care locations within the general acute care hospital setting. || Includes only in-hospital rehabilitation wards that are not defined as inpatient rehabilitation facilities (IRF) per the CMS Inpatient Rehabilita-

tion Facility Quality Reporting Program.


17

Table 6. Pooled means and key percentiles of the distribution of ventilator-associated PNEU rates and ventilator utilization ratios, by type of location, DA module, 2011

Ventilator-associated PNEU rate* Percentile

Type of location No.

of

loca

tions

+

No.

of

VAP

Venti

lato

r -d

ays

Pool

ed

mea

n

10%

25%

50%

(m

edia

n)

75%

90%


Critical Care UnitsBurn 31 (30) 88 17,844 4.9 0.0 0.0 4.2 8.8 12.5Medical -Major teaching 89 188 174,412 1.1 0.0 0.0 0.7 1.8 3.0Medical -All other 156 (141) 152 156,191 1.0 0.0 0.0 0.0 1.0 3.0Medical cardiac 161 (152) 138 128,369 1.1 0.0 0.0 0.0 1.3 3.8Medical/surgical -Major teaching 123 (118) 461 215,214 2.1 0.0 0.0 1.0 2.3 5.4Medical/surgical -All other ≤15 beds 597 (482) 296 267,272 1.1 0.0 0.0 0.0 1.2 4.3Medical/surgical -All other >15 beds 317 (315) 527 509,492 1.0 0.0 0.0 0.6 1.6 2.8Neurologic 19 64 17,656 3.6Neurosurgical 66 (65) 161 70,894 2.3 0.0 0.0 0.7 3.0 5.9Pediatric cardiothoracic 15 12 28,756 0.4Pediatric medical 11 6 7,385 0.8Pediatric medical/surgical 121 (112) 146 135,585 1.1 0.0 0.0 0.0 1.4 3.2Respiratory 6 0 3,984 0.0Surgical -Major teaching 70 290 122,472 2.4 0.0 0.6 1.7 3.5 6.4Surgical -All other 83 (81) 165 82,363 2.0 0.0 0.0 0.1 2.8 4.7Surgical cardiothoracic 168 (164) 268 154,234 1.7 0.0 0.0 0.6 2.4 5.3Trauma 56 499 106,857 4.7 0.0 0.9 3.1 7.5 13.5Specialty Care Areas/OncologyHematopoietic stem cell transplant 5 (4) 0 1,118 0.0Step-Down UnitsAdult step-down (post-critical care) 73 (59) 41 38,572 1.1 0.0 0.0 0.0 1.0 3.7Step-down NICU (level II) 6 (0) 0 93 0.0Inpatient WardsMedical 34 (21) 1 8,316 0.1 0.0 0.0 0.0 0.0 0.0Medical/surgical 53 (32) 17 23,349 0.7 0.0 0.0 0.0 0.7 2.3Neurosurgical 5 1 3,178 0.3Pediatric medical 6 (5) 0 2,707 0.0Pediatric medical/surgical 10 (8) 0 2,609 0.0Pulmonary 7(5) 6 5,840 1.0Telemetry 5 (3) 1 1,245 0.8Long-Term Acute Care Hospitals‡

Adult critical care 6 2 4,314 0.5Adult ward 144 (139) 114 249,330 0.5 0.0 0.0 0.0 0.6 1.2

18

Ventilator utilization ratio** Percentile

Type of location No.

of

loca

tions

+

Venti

lato

r -d

ays

Patie

nt-

days

Pool

ed

mea

n

10%

25%

50%

(m

edia

n)

75%

90%


Critical Care UnitsBurn 31 17,844 66,570 0.27 0.10 0.16 0.24 0.30 0.42Medical -Major teaching 89 174,412 381,557 0.46 0.29 0.38 0.47 0.57 0.65Medical -All other 156 (153) 156,191 444,893 0.35 0.09 0.19 0.32 0.47 0.56Medical cardiac 161 (160) 128,369 461,148 0.28 0.10 0.17 0.25 0.35 0.43Medical/surgical -Major teaching 123 (122) 215,214 522,459 0.41 0.16 0.26 0.39 0.49 0.59Medical/surgical -All other ≤15 beds 597 (582) 267,272 1,118,363 0.24 0.05 0.11 0.21 0.32 0.44Medical/surgical -All other >15 beds 317 (316) 509,492 1,473,581 0.35 0.18 0.26 0.35 0.44 0.51Neurologic 19 17,656 48,822 0.36Neurosurgical 66 70,894 236,554 0.30 0.14 0.24 0.29 0.38 0.45Pediatric cardiothoracic 15 28,756 64,406 0.45Pediatric medical 11 7,385 22,346 0.33Pediatric medical/surgical 121 135,585 339,407 0.40 0.13 0.20 0.34 0.44 0.52Respiratory 6 3,984 11,366 0.35Surgical -Major teaching 70 122,472 292,517 0.42 0.20 0.30 0.40 0.50 0.57Surgical -All other 83 (82) 82,363 238,048 0.35 0.15 0.23 0.31 0.45 0.52Surgical cardiothoracic 168 154,234 462,733 0.33 0.16 0.22 0.31 0.41 0.51Trauma 56 106,857 225,654 0.47 0.36 0.42 0.48 0.55 0.64Specialty Care Areas/OncologyHematopoietic stem cell transplant 5 1,118 19,480 0.06Step-Down UnitsAdult step-down (post-critical care) 73 38,572 346,418 0.11 0.01 0.03 0.08 0.13 0.31Step-down NICU (level II) 6 93 4,706 0.02Inpatient WardsMedical 34 8,316 168,127 0.05 0.00 0.01 0.02 0.04 0.07Medical/surgical 53 23,349 319,638 0.07 0.00 0.01 0.03 0.07 0.19Neurosurgical 5 3,178 28,557 0.11Pediatric medical 6 2,707 30,620 0.09Pediatric medical/surgical 10 2,609 52,868 0.05Pulmonary 7 5,840 35,269 0.17Telemetry 5 1,245 20,685 0.06Long-Term Acute Care Hospitals‡

Adult critical care 6 4,314 11,806 0.37Adult ward 144 249,330 1,129,832 0.22 0.07 0.12 0.20 0.29 0.40

VAP, ventilator-associated pneumonia.

* Number of VAP x 1000 Number of ventilator-days

** Number of ventilator-days Number of patient-days



19

Table 7. Pooled means and key percentiles of the distribution of central line-associated BSI rates and central line utilization ratios for level III NICUs, DA module, 2011


Birth-weight category No.

of

loca

tions

+

No.

of

CLAB

SI

Cent

ral l

ine-

da

ys

Pool

ed

mea

n

10%

25%

50%

(m

edia

n)

75%

90%

< 750 grams 385 (342) 500 196,659 2.5 0.0 0.0 1.6 4.3 7.8751-1000 grams 405 (351) 339 168,938 2.0 0.0 0.0 0.3 3.2 6.31001-1500 grams 412 (368) 244 186,099 1.3 0.0 0.0 0.0 1.9 4.51501-2500 grams 408 (348) 150 163,339 0.9 0.0 0.0 0.0 0.7 2.7> 2500 grams 413 (331) 154 181,091 0.9 0.0 0.0 0.0 0.3 2.1



of

loca

tions

+

Cent

ral

line-

da

ys

Patie

nt-

days

Pool

ed

Mea

n

10%

25%

50%

(m

edia

n)

75%

90%

< 750 grams 385 (351) 196,659 452,309 0.43 0.29 0.37 0.45 0.57 0.72751-1000 grams 405 (370) 168,938 456,349 0.37 0.23 0.30 0.38 0.47 0.651001-1500 grams 412 (405) 186,099 654,187 0.28 0.14 0.20 0.27 0.38 0.521501-2500 grams 408 (405) 163,339 885,095 0.18 0.05 0.08 0.14 0.22 0.43> 2500 grams 413 (406) 181,091 713,246 0.25 0.06 0.10 0.17 0.30 0.45





20

Table 8. Pooled means and key percentiles of the distribution of central line-associated BSI rates and central line utilization ratios for level II/III NICUs, DA module, 2011



of

loca

tions

+

No.

of

CLAB

SI

Cent

ral l

ine-

da

ys

Pool

ed

mea

n

10%

25%

50%

(m

edia

n)

75%

90%




of

loca

tions

+

Cent

ral l

ine-

da

ys

Patie

nt-

days

Pool

ed

mea

n

10%

25%

50%

(m

edia

n)

75%

90%






21

Table 9. Pooled means and key percentiles of the distribution of ventilator-associated PNEU rates and ventilator utilization ratios for level III NICUs, DA module, 2011



of

loca

tions

+

No.

of

VAP

Venti

lato

r-

days

Pool

ed

mea

n

10%

25%

50%

(m

edia

n)

75%

90%




of

loca

tions

+

Venti

lato

r-

days

Patie

nt-

days

Pool

ed

mea

n

10%

25%

50%

(m

edia

n)

75%

90%

< 750 grams 127 (118) 57,133 147,932 0.39 0.22 0.30 0.43 0.55 0.66751-1000 grams 125 (118) 32,501 145,520 0.22 0.07 0.13 0.22 0.34 0.481001-1500 grams 130 (127) 19,974 185,367 0.11 0.02 0.05 0.08 0.16 0.281501-2500 grams 129 (128) 17,250 253,259 0.07 0.01 0.02 0.04 0.09 0.19> 2500 grams 128 29,102 230,077 0.13 0.02 0.03 0.07 0.14 0.23

VAP, ventilator-associated pneumonia; NICU, neonatal intensive care unit.




22

Table 10. Pooled means and key percentiles of the distribution of ventilator-associated PNEU rates and ventilator utilization ratios for level II/III NICUs, DA module, 2011



of

loca

tions

+

No.

of

VAP

Venti

lato

r-

days

Pool

ed

mea

n

10%

25%

50%

(m

edia

n)

75%

90%




of

loca

tions

+

Venti

lato

r-

days

Patie

nt-

days

Pool

ed

mea

n

10%

25%

50%

(m

edia

n)

75%

90%




† The number in parentheses is the number of locations meeting minimum requirements for percentile distributions (i.e., ≥ 50 device days for rate distributions, ≥ 50 patient days for device utilization ratios) if less than total number of locations. If this number < 20, percentile distributions are not calculated.

23

Table 11. Distribution of criteria for central line-associated laboratory-confirmed BSI by location, 2011

Type of LocationLBCI

Criterion 1 n (%) Criterion 2/3 n (%) TotalAcute Care Hospitals

Critical CareBurn 281 93.4% 20 6.6% 301Medical -Major teaching 605 86.1% 98 13.9% 703Medical -All other 620 80.6% 149 19.4% 769Medical cardiac 542 80.5% 131 19.5% 673Medical/surgical -Major teaching 783 83.6% 154 16.4% 937Medical/surgical -All other ≤15 beds 1,003 80.5% 243 19.5% 1,246Medical/surgical -All other > 15 beds 1,540 78.6% 419 21.4% 1,959Neurologic 55 72.4% 21 27.6% 76Neurosurgical 220 71.2% 89 28.8% 309Pediatric cardiothoracic 143 79.4% 37 20.6% 180Pediatric medical 32 94.1% 2 5.9% 34Pediatric medical/surgical 567 79.1% 150 20.9% 717Pediatric surgical 3 100.0% 0 0.0% 3Respiratory 8 100.0% 0 0.0% 8Surgical -Major teaching 406 79.0% 108 21.0% 514Surgical -All other 360 83.9% 69 16.1% 429Surgical cardiothoracic 641 84.1% 121 15.9% 762Trauma 437 85.5% 74 14.5% 511Step-Down UnitsAdult step-down (post-critical care) 486 82.7% 102 17.3% 588Step-down NICU (level II) 4 50.0% 4 50.0% 8Pediatric step-down (post-critical care) 17 89.5% 2 10.5% 19Inpatient WardsAcute stroke 8 80.0% 2 20.0% 10Antenatal 0 0.0% 1 100.0% 1Behavioral health/psychiatry 4 100.0% 0 0.0% 4Burn 5 100.0% 0 0.0% 5Genitourinary 14 73.7% 5 26.3% 19Geronotology 7 100.0% 0 0.0% 7Gynecology 6 85.7% 1 14.3% 7Jail 10 90.9% 1 9.1% 11Labor, delivery, recovery, postpartum suite 1 100.0% 0 0.0% 1Medical 764 84.1% 144 15.9% 908Medical/surgical 1,347 83.9% 259 16.1% 1,606Neurologic 38 86.4% 6 13.6% 44Neurosurgical 37 78.7% 10 21.3% 47Orthopedic 72 73.5% 26 26.5% 98Orthopedic trauma 27 84.4% 5 15.6% 32Pediatric medical 54 87.1% 8 12.9% 62Pediatric medical/surgical 160 81.2% 37 18.8% 197Pediatric rehabilitation - non-IRF|| 7 100.0% 7Pediatric surgical 20 95.2% 1 4.8% 21Postpartum 1 100.0% 0 0.0% 1Pulmonary 45 86.5% 7 13.5% 52

24

Rehabilitation - non-IRF|| 9 90.0% 1 10.0% 10Surgical 335 81.7% 75 18.3% 410Telemetry 163 86.7% 25 13.3% 188Vascular Surgery 13 92.9% 1 7.1% 14Well-Baby Nursery 1 50.0% 1 50.0% 2Inpatient Long Term Care§

Chronic care 5 100.0% 0 0.0% 5Ventilator dependent unit 16 84.2% 3 15.8% 19Long-Term Acute Care Hospitals‡

Adult critical care 68 89.5% 8 10.5% 76Adult Ward 1,204 84.1% 227 15.9% 1,431Inpatient Rehabilitation Facilities¶

Adult rehabilitation units - Freestanding 21 91.3% 2 8.7% 23Adult rehabilitation units - Within hospital 38 88.4% 5 11.6% 43Total 13,253 82.5% 2,854 17.8% 16,064

BSI, bloodstream infection; LCBI, laboratory-confirmed BSI.7


§ Includes inpatient long term care locations within the general acute care hospital setting. || Includes only in-hospital rehabilitation wards that are not defined as inpatient rehabilitation facilities (IRF) per the CMS Inpa-

tient Rehabilitation Facility Quality Reporting Program.

¶ Includes free-standing inpatient rehabilitation facilities and inpatient rehabilitation facilities within the acute care hospital set-ting, as defined by the CMS Inpatient Rehabilitation Facility Quality Reporting Program.

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Table 12. Distribution of criteria for permanent and temporary central line-associated laboratory-confirmed BSI by location, 2011

Type of locationLCBI

TotalCriterion 1 n (%) Criterion 2/3 n (%)Permanent Central Line

Hematopoietic stem cell transplant 219 76.8% 66 23.2% 285General hematology/oncology 307 76.8% 93 23.3% 400Pediatric hematopoietic stem cell transplant 55 82.1% 12 17.9% 67Pediatric general hematology/oncology 175 82.5% 37 17.5% 212Solid organ transplant 24 88.9% 3 11.1% 27Total 780 78.7% 211 21.3% 991Temporary Central Line

Hematopoietic stem cell transplant 164 80.4% 40 19.6% 204General hematology/oncology 387 81.5% 88 18.5% 475Pediatric hematopoietic stem cell transplant 9 81.8% 2 18.2% 11Pediatric general hematology/oncology 69 82.1% 15 17.9% 84Solid organ transplant 47 81.0% 11 19.0% 58Total 676 81.3% 156 18.8% 832


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Table 13. Distribution of specific sites of urinary catheter-associated UTI by location, 2011Type of Location SUTI n (%) ABUTI n (%) Total


Critical CareBurn 147 99.3% 1 0.7% 148Medical -Major teaching 728 98.5% 11 1.5% 739Medical -All other 541 98.0% 11 2.0% 552Medical cardiac 588 98.7% 8 1.3% 596Medical/surgical -Major teaching 816 98.7% 11 1.3% 827Medical/surgical -All other ≤15 beds 901 97.8% 20 2.2% 921Medical/surgical -All other > 15 beds 1,652 98.0% 33 2.0% 1,685Neurologic 115 99.1% 1 0.9% 116Neurosurgical 810 99.8% 2 0.2% 812Pediatric cardiothoracic 12 100.0% 12Pediatric medical 5 100.0% 5Pediatric medical/surgical 212 97.7% 5 2.3% 217Pediatric 1 100.0% 1Respiratory 11 100.0% 11Surgical -Major teaching 548 99.3% 4 0.7% 552Surgical -All other 356 97.3% 10 2.7% 366Surgical cardiothoracic 551 98.4% 9 1.6% 560Trauma 771 99.4% 5 0.6% 776Specialty Care Areas/OncologyHematopoietic stem cell transplant 28 100.0% 28General hematology/oncology 159 98.1% 3 1.9% 162Pediatric general hematology/oncology 4 100.0% 4Solid organ transplant 21 100.0% 21Step-Down UnitsAdult step-down (post-critical care) 749 98.0% 15 2.0% 764Pediatric step-down (post-critical care) 3 100.0% 3Inpatient WardsAcute stroke 22 95.7% 1 4.3% 23Behavioral health/psychiatry 19 100.0% 19Burn 11 100.0% 11Genitourinary 16 100.0% 16Geronotology 11 100.0% 11Gynecology 17 100.0% 17Jail 4 100.0% 4Labor and delivery 5 100.0% 5Labor, delivery, recovery, postpartum suite 15 93.8% 1 6.3% 16Medical 961 98.2% 18 1.8% 979Medical/surgical 1,959 99.0% 20 1.0% 1,979Neurologic 95 100.0% 95Neurosurgical 126 100.0% 126Orthopedic 306 99.4% 2 0.6% 308Orthopedic trauma 32 100.0% 32Pediatric medical/surgical 38 100.0% 38Pediatric medical 6 100.0% 6Pediatric surgical 9 100.0% 9Postpartum 32 100.0% 32Pulmonary 64 95.5% 3 4.5% 67

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Rehabilitation - non-IRF|| 44 97.8% 1 2.2% 45Surgical 654 99.1% 6 0.9% 660Telemetry 131 99.2% 1 0.8% 132Vascular Surgery 15 100.0% 15Inpatient Long Term Care§

Chronic care 12 100.0% 12Long-term care rehabilitation unit 18 100.0% 18Long-Term Acute Care Hospitals‡

Adult critical care 17 100.0% 17Adult Ward 1,391 98.9% 15 1.1% 1,406Inpatient Rehabilitation Facilities¶

Adult rehabilitation units - Freestanding 164 100.0% 164Adult rehabilitation units - Within hospital 143 97.3% 4 2.7% 147Total 16,066 98.7% 217 1.3% 16,283

UTI, urinary tract infection; SUTI, symptomatic UTI; ABUTI, asymptomatic bacteremic UTI.7


§ Includes inpatient long term care locations within the general acute care hospital setting. || Includes only in-hospital rehabilitation wards that are not defined as inpatient rehabilitation facilities (IRF) per the CMS Inpatient

Rehabilitation Facility Quality Reporting Program.


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Table 14. Distribution of specific sites of ventilator-associated pneumonia by location, 2011Type of location PNU1 n (%) PNU2 n (%) PNU3 n (%) Total


Critical Care Units

Burn 37 42.0% 51 58.0% 88Medical -Major teaching 117 62.2% 68 36.2% 3 1.6% 188Medical -All other 124 81.6% 28 18.4% 152Medical cardiac 76 55.1% 62 44.9% 138Medical/surgical -Major teaching 213 46.2% 245 53.1% 3 0.7% 461Medical/surgical -All other ≤15 beds 214 72.3% 75 25.3% 7 2.4% 296Medical/surgical -All other >15 beds 309 58.6% 204 38.7% 14 2.7% 527Neurologic 19 29.7% 45 70.3% 64Neurosurgical 79 49.1% 81 50.3% 1 0.6% 161Pediatric cardiothoracic 9 75.0% 3 25.0% 12Pediatric medical 6 100.0% 6Pediatric medical/surgical 111 76.0% 34 23.3% 1 0.7% 146Surgical -Major teaching 142 49.0% 138 47.6% 10 3.4% 290Surgical -All other 80 48.5% 82 49.7% 3 1.8% 165Surgical cardiothoracic 154 57.5% 107 39.9% 7 2.6% 268Trauma 244 48.9% 251 50.3% 4 0.8% 499Step-Down Units

Adult step-down (post-critical care) 35 85.4% 6 14.6% 41Inpatient Wards

Medical 1 100.0% 1Medical/surgical 5 29.4% 12 70.6% 17Neurosurgical 1 100.0% 1Pulmonary 6 100.0% 6Telemetry 1 100.0% 1Long Term Acute Care*

Adult critical care 1 50.0% 1 50.0% 2Adult ward 82 71.9% 32 28.1% 114Total 2,060 56.5% 1,530 42.0% 54 1.5% 3,644

PNU1, clinically defined pneumonia; PNU2, pneumonia with specific laboratory findings; PNU3, pneumonia in immunocompromised patients.7

* Includes free-standing long-term acute care hospitals and long-term acute care locations within the general acute care hospital setting.

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Table 15. Distribution of specific sites and criteria for central line-associated laboratory-confirmed BSI among Level III NICUs by birthweight, 2011

Birth-weight categoryLCBI

TotalCriterion 1 n (%) Criterion 2/3 n (%)≤ 750 grams 346 69.2% 154 30.8% 500751-1000 grams 216 63.7% 123 36.3% 3391001-1500 grams 156 63.9% 88 36.1% 2441501-2500 grams 106 70.7% 44 29.3% 150> 2500 grams 118 76.6% 36 23.4% 154Total 942 67.9% 445 32.1% 1387


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Table 16. Distribution of specific sites and criteria for central line-associated laboratory-confirmed BSI among Level II/III NICUs by birthweight, 2011

Birth-weight categoryLCBI

TotalCriterion 1 n (%) Criterion 2/3 n (%)≤ 750 grams 194 65.8% 101 34.2% 295751-1000 grams 119 61.7% 74 38.3% 1931001-1500 grams 86 58.5% 61 41.5% 1471501-2500 grams 55 63.2% 32 36.8% 87> 2500 grams 50 64.9% 27 35.1% 77Total 504 63.1% 295 36.9% 799


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Table 17. Distribution of specific sites of ventilator-associated pneumonia among Level III NICUs by birthweight, 2011

Birth-weight category PNU1 n (%) PNU2 n (%) PNU3 n (%) Total≤ 750 grams 62 69.7% 26 29.2% 1 1.1% 89751-1000 grams 29 61.7% 17 36.2% 1 2.1% 471001-1500 grams 15 75.0% 5 25.0% 201501-2500 grams 6 66.7% 3 33.3% 9> 2500 grams 6 100.0% 6Total 118 69.0% 51 29.8% 2 1.2% 171


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Table 18. Distribution of specific sites of ventilator-associated pneumonia among Level II/III NICUs by birthweight, 2011

Birth-weight category PNU1 n (%) PNU2 n (%) PNU3 n (%) Total≤ 750 grams 37 75.5% 7 14.3% 5 10.2% 49751-1000 grams 14 66.7% 5 23.8% 2 9.5% 211001-1500 grams 6 85.7% 1 14.3% 71501-2500 grams 7 100.0% 7> 2500 grams 2 100.0% 2Total 66 76.7% 13 15.1% 7 8.1% 86


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Appendix A. How to calculate a device-associated infection rate and device utilization ratio with Device-associated Module data

Calculation of Device-associated Infection RateStep 1: Decide upon the time period for your analysis. It may be a month, a quarter, 6 months, a year, or some other period.

Step 2: Select the patient population for analysis, e.g., the type of location or a birthweight category in a NICU.

Step 3: Select the infections to be included in the numerator. They must be site-specific and must have occurred in the se-lected patient population. Their date of onset must be during the selected time period.

Step 4: Determine the number of device-days which is used as the denominator of the rate. Device-days are the total number of days of exposure to the device (central line, umbilical catheter, ventilator, or urinary catheter) by all of the patients in the selected population during the selected time period.

Example: Five patients on the first day of the month had one or more central lines in place; five on day 2; two on day 3; five on day 4; three on day 5; four on day 6; and four on day 7. Adding the number of patients with central lines on days 1 through 7, we would have 5+5+2+5+3+4+4=28 central line-days for the first week. If we continued for the entire month, the number of central line-days for the month is simply the sum of the daily counts.

Step 5: Calculate the device-associated infection rate (per 1000 device-days) using the following formula:

Device-associated Infection Rate = Number of device-associated infections for an infection site x 1000 Number of device-days

Example: Central line-associated BSI rate per 1000 central line-days = Number of central line-associated BSI x 1000 Number of central line-days

Calculation of Device Utilization (DU) RatioSteps 1,2,4: Same as device-associated infection rates plus determine the number of patient-days which is used as the

denominator of the DU ratio. Patient-days are the total number of days that patients are in the location during the selected time period.

Example: Ten patients were in the unit on the first day of the month; 12 on day 2; 11 on day 3; 13 on day 4; 10 on day 5; 6 on day 6; and 10 on day 7; and so on. If we counted the patients in the unit from days 1 through 7, we would add 10 + 12 + 11 + 13 + 10 + 6 + 10 for a total of 72 patient-days for the first week of the month. If we continued for the entire month, the number of patient-days for the month is simply the sum of the daily counts.

Step 5: Calculate the DU ratio with the following formula:

DU Ratio = Number of device-days Number of patient-days

With the number of device-days and patient-days from the examples above, DU = 28/72 = 0.39 or 39% of patient-days were also central line-days for the first week of the month.

Step 6: Examine the size of the denominator for your hospital’s rate or ratio. Rates or ratios may not be good estimates of the “true” rate or ratio for your hospital if the denominator is small, i.e., <50 device-days or patient-days.

Step 7: Compare your hospital’s location-specific rates or ratios with those found in the tables of this report. Refer to Appen-dix B for interpretation of the percentiles of the rates/ratios.

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Appendix B. Interpretation of percentiles of infection rates or device utilization ratiosStep 1: Evaluate the rate (ratio) you have calculated for your hospital and confirm that the variables in the rate (both numer-

ator and denominator) are identical to the rates (ratios) in the table.

Step 2: Examine the percentiles in each of the tables and look for the 50th percentile (or median). At the 50th percentile, 50% of the hospitals have lower rates (ratios) than the median and 50% have higher rates (ratios).

Step 3: Determine if your hospital’s rate (ratio) is above or below this median.

Determining whether your hospital’s rate or ratio is a HIGH outlierStep 4: If it is above the median, determine whether the rate (ratio) is above the 75th percentile. At the 75th percentile,

75% of the hospitals had lower rates (ratios) and 25% of the hospital had higher rates (ratios).

Step 5: If the rate (ratio) is above the 75th percentile, determine whether it is above the 90th percentile. If it is, then the rate (ratio) is an outlier which may indicate a problem.

Determining whether your hospital’s rate or ratio is a LOW outlierStep 6: If it is below the median, determine whether the rate (ratio) is below the 25th percentile. At the 25th percentile,

25% of the hospitals had lower rates (ratios) and 75% of the hospitals had higher rates (ratios).

Step 7: If the rate (ratio) is below the 25th percentile, determine whether it is below the 10th percentile. If it is, then it is a low outlier which may be due to underreporting of infections. If the ratio is below the 10th percentile, it is a low outlier and may be due to infrequent and/or short duration of device use.

Note: Device-associated infection rates and device utilization ratios should be examined together so that preventive measures may be appropriately targeted. For example, you find that the ventilator-associated pneumonia rate for a certain type of ICU is consistently above the 90th percentile and the ventilator utilization ratio is routinely between the 75th and 90th percen-tile. Since the ventilator is a significant risk factor for pneumonia, you may want to limit the duration of ventilation whenever possible (i.e., decrease unnecessary use) while at the same time optimize infection prevention strategies in patients for which ventilator use is required.

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References1 Dudeck MA, Horan TC, Peterson KD, Allen-Bridson K, Morrell GC, Pollock DA, Edwards JR. National Healthcare Safety Network

(NHSN) report, data summary for 2010, device-associated module. Am J Infect Control 2011; 39:798-816.

2 Centers for Disease Control and Prevention. State-specific HAI standardized infection ratio (SIR) report, January-June 2009. Avail-able from: http://www.cdc.gov/HAI/pdfs/stateplans/SIR_05_25_2010.pdf. Accessed October 25, 2012.

3 Centers for Disease Control and Prevention. National HAI standardized infection ratio (SIR) report, July-December 2009. Available from: http://www.cdc.gov/HAI/pdfs/stateplans/SIR-2010_JunDec2009.pdf. Accessed October 25, 2012.

4 Centers for Disease Control and Prevention. State-specific supplement to the national healthcare-associated infection standard-ized infection ratio (SIR) report: July 2009 through December 2009. Available from: http://www.cdc.gov/HAI/pdfs/stateplans/state-specific-hai-sir-july-dec2009r.pdf. Accessed October 25, 2012.

5 Centers for Disease Control and Prevention. Outline for healthcare-associated infection surveillance. Available from: http://www.cdc.gov/nhsn/PDFS/OutlineForHAISurveillance.pdf . Accessed October 25, 2012.

6 Centers for Disease Control and Prevention. NHSN manual: patient safety component protocols. Available from: http://www.cdc.gov/nhsn/TOC_PSCManual.html. Accessed October 25, 2012.

7 Centers for Disease Control and Prevention. Surveillance definition of healthcare-associated infection and criteria for specific types of infections in the acute care setting. Available from: http://www.cdc.gov/nhsn/PDFs/pscManual/17pscNosInfDef_current.pdf. Accessed October 25, 2012.

8 Klevens RM, Edwards JR, Andrus ML, Peterson KD, Dudeck MA, Horan TC and the NHSN participants in Outpatient Dialysis Surveil-lance. Dialysis Surveillance Report: National Healthcare Safety Network (NHSN)--Data Summary for 2006. Seminars in Dialysis 2008;21(1):24-28.

9 Jarvis WR, Edwards JR, Culver DH, Hughes JM, Horan T, Emori TG, et al. Nosocomial infection rates in adult and pediatric intensive care units in the United States. Am J Med 1991;91(Suppl 3B):185S-91S.

10 Centers for Disease Control and Prevention. Ventilator-associated events. Available from: http://www.cdc.gov/nhsn/psc_da-vae.html. Accessed December 20, 2012.

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